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ATNG Nutrition Pre-Assessment Form
ATNG Nutrition Pre-Assessment Form
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53Questions
ATNG Nutrition Pre-Assessment Form
  • 1
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  • 3
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  • 4
    Please state how tall you are.
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  • 5
    Please state your most recent weight.
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  • 6
    Are you comfortable having your body weight assessed at our office?
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  • 7
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  • 8
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  • 9
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  • 10
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  • 11
    Please list medications you are currently taking. Specify the dose of each medication if you can. Nutritional supplements are addressed in the next question.
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  • 12
    Please list Vitamin and/ or Herbal supplements  you are currently taking. Specify the dose of each supplement  if you know what it is, and also state how often you take the supplement.
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  • 13
    YOUR HEALTH HISTORY
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  • 14
    Please list any other condition you may have that you would like your nutritionist to know about. 
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  • 15
    FAMILY HISTORY
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  • 16
    Please provide a brief history regarding body weight. You may include information regarding your highest and lowest adult weight, any previous weight loss methods, or anything else you feel may be helpful such as unintentional weight changes.
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  • 17
    Sleep patterns can affect your health and your nutritional intake.
    • < 7 hours per night
    • 7 - 9 hours per night
    • > 9 hours each night
    • Yes
    • No
    • Sometimes
    • No, I do not wake up at night
    • I sometimes wake up
    • Yes, I often wake up
    • Yes
    • No
    • Sometimes
    • Seldom
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  • 18
    Please describe your energy levels during the day. Are there any times in the day when you feel a slump in energy levels or feel particularly tired?
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  • 19
    • I have never used tobacco/ nicotine Products
    • I am a previous smoker, but no longer use tobacco/nicotine products
    • I am a current smoker and use tobacco/nicotine products.
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  • 20
    How many days, months or years since  you last used tobacco or nicotine products?
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  • 21
    Do you participate in any formal exercise apart from the activity  you get  from your daily routine
    • No
    • Sometimes, but not consistently
    • Yes, routinely each week
    • Yes, daily
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  • 22
    This section is used to identify your usual weekly activity level
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  • 23
    • Yes
    • No
    • Less than 1-times per week, I seldom consume alcohol
    • 1-3 times per week
    • 3-5 times per week
    • 5 or more times per week
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  • 24
    STRESS ASSESSMENT SCALE
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  • 25
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  • 26
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  • 27
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  • 28
    • Yes
    • No
    • Yes
    • No
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  • 29
    Are you following a strict vegetarian diet that excludes all animal food products?
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  • 30
    Please check all the beverages that you usually consume.
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  • 31
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  • 32
    Please check all that apply to you
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  • 33
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  • 34
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  • 35
    Do you use regular Milk and Dairy Products such as cheese and yogurt as part of your usual diet
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  • 36
    Please check all that apply to you
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  • 37
    Do you eat read meat products?
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  • 38
    Please select all the products you eat as part of your usual eating a habits
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  • 39
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  • 40
    Please check all that apply to you
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  • 41
    Do you eat Eggs
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  • 42
    Do you usually eat fish and/or shellfish?
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  • 43
    Please select all the items you usually eat
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  • 44
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  • 45
    Please check all the foods you usually eat
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  • 46
    Please check all the foods that you usually eat
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  • 47
    Please check all the foods that you usually use
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  • 48
    Please check all the foods that you usually use
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  • 49
    Please list dietary restrictions that apply to you.
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  • 50
    This question is asked so that we can understand more about how meals are prepared and shared  in your home and the logistics involved with grocery shopping, etc. 
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  • 51
    Please let us know more about the tracking Tools/ Apps you have used to monitor your food intake or activity
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  • 52
    Please check all of the boxes that apply to you
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  • 53
    Tell us more about how you get the meals you usually eat.
    • Never
    • Rarely/ Seldom
    • Weekly
    • Daily
    • Never
    • 2-4 times per month
    • 2-3 times per week
    • 4 or more times per week
    • Never
    • 2-4 times per month
    • 2-3 times per week
    • 4 or more times per week
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  • 54
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